Provider Demographics
NPI:1356545800
Name:LAKEVILLE FAMILY MEDICINE PC
Entity type:Organization
Organization Name:LAKEVILLE FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-947-6666
Mailing Address - Street 1:5 PRECINCT ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02347-1427
Mailing Address - Country:US
Mailing Address - Phone:508-947-6666
Mailing Address - Fax:
Practice Address - Street 1:5 PRECINCT ST
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MA
Practice Address - Zip Code:02347-1427
Practice Address - Country:US
Practice Address - Phone:508-947-6666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA81226261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM17688OtherMASS BLUE CROSS